First Name

Last Name

NPI *

Phone *

Email *

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Licensure and eligibility *

I hold or my medical director holds an active, unrestricted license authorizing these products in every state where they will be received, dispensed, or administered, and neither of us is excluded from any federal or state healthcare program.

Product regulatory status *

I understand that no V2 Sciences product is FDA-approved for any indication, and that products labeled For Research Use Only must not be administered to any human or animal.

Clinical responsibility *

I accept sole responsibility for all clinical decisions, including patient selection, dosing, informed consent, monitoring, and adverse event reporting.

V2 Terms and Conditions *

I agree to the V2 Sciences Terms and Conditions v1.0, including indemnification, no warranties, limitation of liability, and binding individual arbitration in Idaho with a class action waiver.

I consent to conduct this transaction electronically. I agree that my electronic signature below has the same legal effect as a handwritten signature under the federal ESIGN Act (15 U.S.C. § 7001) and the Idaho Uniform Electronic Transactions Act (Idaho Code § 28-50-101). I have had the opportunity to review the full V2 Sciences Terms and Conditions and to consult legal counsel. I may request a free paper copy of this agreement, or withdraw my consent to electronic records, by emailing [email protected]. Viewing and retaining these records requires a current web browser, an active email account, and the ability to open PDF files.